Nirmala Pillalamarri1 and Harvey Winkler1
(1)
Division of Female Pelvic Medicine and Reconstructive Surgery, North Shore—Long Island Jewish Health System, Great Neck, NY, USA
Nirmala Pillalamarri
Email: npillalama@nshs.edu
Harvey Winkler (Corresponding author)
Email: hwinkler@nshs.edu
Introduction
Benign lesions of the vagina or vulva include cystic tumors, solid tumors, and dermatoses. Of these benign lesions, cysts are the most common. A cyst is an enclosed pocket or pouch of tissue that can be filled with materials such as air, fluid, or pus. Several types of vaginal and vulvar cysts exist and can range in size from millimeters to many centimeters. The evaluation, management, and treatment of vaginal and vulvar cysts has remained rather constant over the years and will be explored in this chapter.
Embryology and Anatomy
Embryology
A rudimentary understanding of embryology of the genital tract is useful when evaluating vaginal and vulvar anomalies such as cysts [1]. The urogenital system is comprised of the urinary tract (kidneys, ureters, bladder, and urethra) while the genital tract contains the gonads, ductal system, and external genitalia. The formation of the urogenital system in an embryo begins when a fold of intermediate mesoderm forms along each side of the abdominal aorta in early development. These folds are termed the urogenital ridges, each of which then separates into a nephrogenic ridge and a genital ridge.
The Urinary Tract
Creation of the urinary tract begins when the nephrogenic ridges give rise to the mesonephric, or Wolffian, ducts. These ducts connect the mesonephric kidneys to the cloaca, a distal pouch where the urinary, genital, and alimentary tracts culminate. By the 5th week of fetal life, each mesonephric duct gives rise to a ureteric bud. Subsequently the ureteric bud becomes a metanephric duct, also called the ureter. The ureter causes formation of the metanephros, which becomes the adult kidney. Concomitantly, the mesonephric kidney degenerates by the 10th week of life.
The Genital Tract
At 5 weeks of gestation, the gonads are undifferentiated and have the capability of becoming either ovaries or testes. After differentiation into ovaries, the formation of the genital tract begins. The paramesonephric ducts, also known as the mullerian ducts, develop bilaterally from an invagination of the coelomic epithelium between the gonad and mesonephric duct at 6 weeks of gestation. Both the mullerian and mesonephric ducts end at the posterior aspect of the cloaca. The cloaca divides to form the urogenital sinus anteriorly, and the rectum posteriorly. The urogenital sinus is composed of three parts, including the vesicle portion that later becomes the bladder, the middle portion that becomes the urethra, and the caudal portion that becomes the distal vagina including the Bartholin (greater vestibular) glands, urethral glands, and Skene (paraurethral) glands (Fig. 14.1). The most inferior aspects of the mesonephric and metanephric ducts enter the trigone of the bladder. At 12 weeks of gestation, the inferior portion of the mullerian ducts fuses to create the uterovaginal canal. By 20 weeks, the uterovaginal canal develops into the uterus and upper vagina. The superior aspects of the mullerian ducts do not fuse, instead becoming the fallopian tubes.
Fig. 14.1
Bartholin gland and Skene/paraurethral gland duct openings within the vagina
The Vagina
The formation of the vagina starts with the development of two solid sinovaginal bulbs in the superior aspect of the vaginal portion of the urogenital sinus. These bulbs grow distally and form a solid vaginal plate. As the central aspect of the vaginal plate disintegrates, the lumen of the lower vagina is created and completed by 20 weeks. This lower vaginal lumen is separated from the more superior urogenital sinus and uterovaginal canal by the hymenal membrane. This membrane disintegrates centrally before birth, leaving behind a circumferential tissue band within the distal vagina and proximal to the vaginal introitus [2].
Anatomy
Vaginal Structure and Histology
Knowledge of pertinent normal lower genital tract anatomy is also useful when identifying vaginal and vulvar cysts [3]. The vagina, an empty tubular structure with a lumen that is held in place by its surrounding muscular and connective tissue support structures, sits between the bladder and rectum. The most proximal aspect of the vagina, the vaginal apex, heads posteriorly toward the ischial spines. Normal vaginal length is generally between 7 and 10 cm. In the absence of prior total hysterectomy, the cervix is present at the vaginal apex. The outer portion of the cervix (the ectocervix) is made of nonkeratinized stratified squamous cells and the inner portion and canal of the cervix (the endocervix) is comprised of simple columnar cells. Where these two different cell types meet is termed the transformation zone. The vaginal walls consist of three layers. The first layer in direct communication with the vaginal lumen is the vaginal epithelium (also referred to as “mucosa” despite an absence of glands) that is made of nonkeratinized stratified squamous epithelium. Deep to the mucosa is the muscularis that contains smooth muscle, collagen, and elastin. The deepest layer is the adventitia that is made of collagen and elastin connective tissue. The muscularis and adventitia together are referred to as the fibromuscular layer, and is commonly referred to as the pubovesicocervical fascia anterior to the vagina or the rectovaginal fascia posterior to the vagina. On the lateral aspects of the vagina, the adventitia extends out to the pelvic walls and contains fat, lymphatics, and neurovasculature.
Vaginal Neurovasculature
Blood is supplied to the vagina from the descending cervical branch of the uterine artery and branches of the internal iliac artery including the vaginal, middle rectal, and internal pudendal arteries. Lymphatic drainage of the upper two-thirds of the vagina is to the obturator nodes as well as the external and internal iliac nodes, while the lower third of the vagina drains to the inguinal nodes [4]. Portions of the inferior hypogastric plexus are responsible for sympathetic innervation of the vagina [5].
The Urethra
The urethra, which averages 3 cm in length, rests on and is supported by an endopelvic fascial layer and the anterior vaginal wall [6, 7]. It is comprised of four layers: mucosa, submucosa, internal urethral sphincter made of smooth muscle, and striated external urethral sphincter made of skeletal muscle. The inner surface of the proximal urethra is lined by transitional epithelium while the distal urethra is lined by stratified squamous epithelium [8]. This epithelium is continuous with bladder epithelium proximally and with that of the vaginal vestibule distally. Paraurethral glands open into the urethral lumen within this layer in the dorsal or vaginal side of the distal urethra [9]. The most pronounced of these paraurethral glands are the Skene glands that can be visible on the inner surface of the external urethral meatus. Blood supply to the urethra comes from the internal pudendal, vaginal, and inferior vesical arteries, while nerve supply comes from the pudendal nerve for somatic control and portions of the inferior hypogastric plexus for autonomic control [10]. The lymphatics of the distal third of the urethra drain into the superficial or deep inguinal nodes, whereas the proximal two-thirds drain into the external iliac, internal iliac, and obturator nodes.
The Vulva
The vulva is the term for the female external genitalia and includes the mons pubis, labia majora, labia minora, clitoris, vestibule, vestibular bulbs, vestibular glands, Bartholin (greater vestibular) glands, Skene (paraurethral) glands, external urethral meatus, and vaginal orifice. The skin over the mons pubis and labia majora has hair and a fatty subcutaneous layer. The obliterated processus vaginalis, or canal of Nuck, and the round ligament exit the inguinal canal and terminate within the fat or skin of the labia majora. The skin over the labia minora does not have hair and its subcutaneous tissue is devoid of fat.
The vaginal vestibule is an area in between the labia minora. The specific boundaries include the clitoris anteriorly, the fourchette posteriorly, the Hart line laterally, and the hymen medially. Distal to the Hart line the exposed tissue is a keratinized stratified squamous epithelium, while proximally it is nonkeratinized stratified squamous epithelium. The vestibule also contains the urethral, vestibular, Bartholin, and Skene gland openings.
The Bartholin glands are the female equivalent of the male bulbourethral, or Cowper, glands. One gland is situated at 5 O’clock while the other rests at the 7 O’clock position and each gland possesses a duct that opens into the vaginal vestibule. The inner surfaces of these glands are lined by columnar cells that secrete mucus to provide lubrication [11].
Evaluation and Management
History and Physical
A history and physical exam is the starting point of any vaginal or vulvar cyst workup. Specific symptoms to address in the patient’s history of present illness include the presence or absence of vaginal or vulvar pain, dyspareunia, urethral versus vaginal discharge, spotting, post-void dribbling, leakage of urine, dysuria, incomplete voiding, or palpable mass. The patient should be questioned regarding recent vaginal trauma or placement of foreign body into the vagina. Pertinent aspects in the history include age, known congenital urogenital tract anomalies, obstetrical history including vaginal trauma and repair, sexual activity, recurrent urinary tract infections, prior vaginal surgery, and history of pelvic radiation therapy. Gynecological history including menstrual cycles, prior vaginal infections, endometriosis, fibroids, and exposure to diethylstilbestrol (DES) in utero may be specifically applicable to the patient’s presenting condition.
A targeted physical examination should include bimanual and speculum exams. A pelvic organ prolapse assessment to rule out prolapse as a cause for vaginal bulge symptomatology should be completed. Special attention should be taken to palpation of the anterior vaginal wall; a compressible bulge and discharge per urethra should raise suspicion for urethral diverticulum. Vaginal discharge should be evaluated. Masses such as cystic-appearing bulges should be examined with special attention taken to note the size, location, and tenderness of the cyst.
Differential Diagnosis
Vaginal Cysts
The differential diagnosis of vaginal cysts (Table 14.1) includes epidermal inclusion cysts, mullerian cysts, Gartner duct cysts (mesonephric remnants), and mucous inclusions (adenosis). Less common types of vaginal cysts include endometriotic cysts and vaginitis emphysematosum. Vaginal endometriotic cysts are infrequently encountered as the vagina is a rare location for endometriotic implants to manifest [12]. Although the etiology remains unclear, the benign and self-limited condition of multiple gas-filled cysts lining the vaginal wall (vaginitis emphysematosum) has also been described [13].
Table 14.1
Differential diagnosis of vaginal and vulvar cysts
|
Vaginal cyst |
Vulvar cyst |
|
Epidermal inclusion cyst |
Epidermal inclusion (sebaceous) cyst |
|
Mullerian cyst |
Bartholin (greater vestibular) gland cyst |
|
Gartner duct cyst (mesonephric remnant) |
Skene (paraurethral) gland cyst |
|
Adenosis (mucous inclusions) |
Cyst of the canal of Nuck (hydrocele) |
|
Endometriotic cyst |
Leiomyoma |
|
Vaginitis emphysematosum |
Urethral diverticulum |
Vulvar Cysts
The differential diagnosis of vulvar cysts (Table 14.1) includes vulvar epidermal inclusion (sebaceous) cysts, Bartholin (greater vestibular) gland cysts, Skene (paraurethral) gland cysts, cysts of the canal of Nuck (hydroceles), leiomyoma, and urethral diverticulum (Fig. 14.2; see Chap. 11 on Repair of Urethral Diverticula).
Fig. 14.2
Urethral diverticulum
Overall, the frequency of presentation with a vaginal cyst is uncommon. Patients are more likely to present with symptomatic vulvar cysts. Kondi-Pafiti et al. [14] reviewed 40 cases of benign vulvar and vaginal cysts, the majority of which were asymptomatic. The most common symptomatic cyst was a Bartholin gland cyst. The most frequently encountered cyst was a mullerian cyst (12), followed by a Bartholin gland cyst (11), epidermal inclusion cyst (10), Gartner’s duct cyst (5), endometrioid cyst (1), and one unspecified cyst. Deppisch [15] studied the classification of 64 surgically excised vaginal cysts and found that Gartner’s duct cysts were uncommon, mullerian cysts made up 1/3 of cases, and epithelial inclusion cysts were the most common type of vaginal cyst. These studies are consistent with the general acceptance that epithelial inclusion cysts, mullerian cysts, and Bartholin gland cysts more often cause symptoms and are therefore more likely identified than other types of vulvar or vaginal cysts.
Evaluation of Vaginal Cysts
Epidermal Inclusion Cysts
Epidermal inclusion cysts are often asymptomatic and discovered during routine gynecological exam. However, symptoms may include vaginal pain or dyspareunia and presence of a palpable mass. The appearance is round, pinkish-white in color, and variable in size (Figs. 14.3, 14.4, 14.5, and 14.6). The fluid content can be viscous. Histopathology confirms the diagnosis and reveals epithelial cells lined by a cyst wall made of nonkeratinized stratified squamous epithelium. Asymptomatic cysts can be observed, while drainage or excision should be performed for symptomatic cysts or if there is concern for infection. Additionally, the cyst should be biopsied and drained or excised for patients with a history of cervical, vaginal, or vulvar intraepithelial neoplasia. Hoffman et al. [16] reported on 26 women who were treated for vaginal intraepithelial neoplasia, 22 of whom had undergone prior hysterectomy for benign causes, cervical intraepithelial neoplasia, or malignancy. Five patients were noted to have vaginal cuff inclusion cysts that were found to be positive for a neoplastic process. This finding suggests that when a vaginal epithelial inclusion cyst is identified in a patient with a prior intraepithelial neoplastic process or cancer, biopsy of the cyst should be performed.
Fig. 14.3
Epidermal inclusion cyst arising from right lateral vaginal wall
Fig. 14.4
Epidermal inclusion cyst arising from posterior vaginal wall
Fig. 14.5
Epidermal inclusion cyst (visually difficult to distinguish from pelvic organ prolapse)
Fig. 14.6
Showing base of epidermal inclusion cyst shown in Fig. 14.4 arising from mid-portion of anterior vaginal wall
Gartner Duct Cysts
On physical exam these cysts are typically identified within a lateral wall of the vagina. Gartner duct cysts are mesonephric (Wolffian) duct remnants. During embryonic development the mesonephric ducts are involved in the formation of the urogenital system. In females, after the fundamental urinary system is created, these ducts regress and sometimes leave a remnant behind causing a Gartner duct cyst. They are usually asymptomatic and encountered during routine gynecological exam. When present, symptoms include vaginal pain, dyspareunia, or the awareness of the presence of a mass. Histologically, they are lined with cuboidal or columnar epithelium. Asymptomatic cysts can be observed while symptomatic ones should be marsupialized or excised. If surgical management is pursued, it is important to image the lower reproductive tract because Gartner duct cysts can track cephalad as far as into the broad ligament and an awareness of the cyst dimensions may prove helpful during dissection (Figs. 14.7 and 14.8). Furthermore, imaging is performed to detect renal anomalies with which Gartner duct cysts may be associated [17]. Bats et al. [18] reported a case of malignant transformation of a Gartner cyst in a 67-year-old woman who presented with vaginal bleeding. Pathology from excision revealed clear cell carcinoma. Although the risk of developing carcinoma from a Gartner duct cyst is extremely rare, we suggest performing at least a biopsy if not an excision in patients with vaginal bleeding.
Fig. 14.7
MRI sagittal view of Gartner duct cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.8
MRI transverse view of Gartner duct cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Adenosis
Vaginal adenosis is a condition where mucous inclusions (glandular tissue) are present within the vaginal epithelium. The etiology can be spontaneous, but many affected patients were exposed to diethylstilbestrol (DES) in utero. Symptoms include vaginal discharge, irritation, pruritis, dyspareunia, and postcoital spotting. The area of affected vaginal wall appears erythematous and grainy or possibly with multiple small (millimeter) cysts. Histology displays normal vaginal stratified squamous mucosa containing regions of columnar epithelium. Those patients with a history of DES exposure are at increased risk for developing vaginal clear cell adenocarcinoma. Because of the risk of underlying carcinoma, a colposcopic exam should be performed with biopsy. The condition is usually self-limited; however, if persistent or symptomatic, treatment with carbon dioxide laser coagulation or excision can be considered. See Fig. 14.9a, b.
Fig. 14.9
(a, b) Vaginal adenosis
Vaginitis Emphysematosum
Vaginitis emphysematosum is an uncommon abnormality that produces multiple subcentimeter gas-filled cysts within small connective tissue spaces in the vaginal wall giving it a corrugated appearance. As reported by Leder et al. [19] the etiology of this benign bacterial vaginitis is uncertain, but most reported cases have noted the presence of vaginitis caused by Trichomonas vaginalis or Gardnerella vaginalis. The condition is often discovered in gravid or immunocompromised patients and usually does not cause symptoms. When present, symptoms may include vaginal discharge and pruritis. The condition can be observed on imaging such as X-ray or Computed Tomography (CT) scan. Histology reveals gas spaces beneath the vaginal epithelial pegs that are lined by inflammatory multinucleated giant cells. Vaginitis emphysematosum is benign and self-limiting.
Mullerian Cysts
As most vaginal cysts, mullerian cysts are most often asymptomatic and found on incidental exam. However, symptoms may include dyspareunia and presence of a palpable mass detected either manually or while attempting to insert a tampon. They appear round, smooth, pink, variable in size, and fluid content feels gelatinous when palpated. On exam, it is not possible to distinguish mullerian cysts from inclusion or Gartner’s duct cysts. Histology reveals a columnar epithelial lining. Once again, asymptomatic cysts can be observed whereas incision and drainage or excision should be performed for symptomatic or infected cysts. There have been several case reports documenting vaginal mullerian cysts. In one report, a woman presented with an 8 cm posterior vaginal wall cyst that contained mucoid material [20], while another case reported a large anterior vaginal wall cyst that was evaluated with radiologic studies and subsequently excised [21]. There has been one unusual report of adenocarcinoma arising from a vaginal mullerian cyst in a 48-year-old presenting with a 3 cm ruptured vaginal cyst [22]. This finding highlights the need to have a low threshold for biopsy when larger or persistent anatomical abnormalities are encountered.
Imaging
The role of radiography in evaluation of a vaginal cyst depends on the location and type of cyst suspected after performing a history and physical exam. Based on the initial evaluation, it may be prudent to obtain preoperative information regarding cyst characteristics and its proximity to neighboring structures. For example, Gartner duct cysts (mesonephric remnants) may extend as far cranially as into the broad ligament and preoperative imaging may help determine the extent of intraoperative dissection that will be necessary. Additionally, since Gartner duct cysts can be associated with renal anomalies, preoperative imaging may expose findings such as renal agenesis or ectopic ureter. Sheih et al. [23] found 13 cases of cysts in the pelvis that were associated with ipsilateral renal agenesis or dysplasia after 280,000 children with renal abnormalities were screened with ultrasounds. Seven of the 13 cases found to have pelvic cysts were girls with Gartner duct cysts.
Preoperative imaging may be useful in identifying additional cysts that were not visible on physical exam. Wai et al. [24] reported a case of a 20-year-old woman who presented with two vaginal cysts on exam. Magnetic Resonance Imaging (MRI) was obtained preoperatively and not only demarcated the arrangement of her vaginal cysts, but also identified additional larger cysts that had not been appreciated on physical examination.
Evaluation of Vulvar Cysts
Vulvar Epidermal Inclusion Cysts
Vulvar epidermal inclusion cysts, also known as sebaceous cysts, are the most common vulvar cysts. They form on areas where hair follicles or sebaceous glands are present. Additionally, clitoral epidermal inclusion cysts have been described in patients with a history of female genital mutilation. Rouzi et al. [25] reported on 21 females presenting anywhere between 2 and 20 years after having had a type I female genital mutilation procedure, whereas Ofodile et al. [26] described 19 cases. Most vulvar inclusion cysts are asymptomatic. When present, symptoms include pain to touch and bothersome appearance. These cysts appear firm, are often mobile, and contain caseous material. They run the risk of becoming infected and developing into cellulitis or an abscess. Obstruction of the duct leads to buildup of secretions and consequently cyst formation. Treatment includes warm compresses to drain the obstructed duct. Recurrent, persistent, or enlarging cysts can be treated with incision and drainage, punch biopsy with subsequent drainage, or excision. The type of excision may depend on the cyst size (to be described later in the chapter). In a randomized prospective study of 60 patients with nonspecifically located noninfected vulvar epidermal inclusion cysts, Lee et al. [27] compared results after treatment with the punch biopsy technique versus excision. The study group found that those treated with the punch biopsy method produced superior cosmetic results, while there was no difference in recurrence rates over the 16-month time period they were studied.
Bartholin Gland Cysts
Like other vulvar cysts, Bartholin gland duct cysts form when the duct gets obstructed and accumulation of gland secretions leads to cyst formation. If the cyst becomes infected an abscess forms. A single organism may be causative or the infection may be polymicrobial. Anaerobic and aerobic bacteria are often the organisms involved, and Neisseria gonorrhoeae or Chlamydia trachomatis only rarely. In fact, Bhide et al. [28] found that 74 % of 78 cases reviewed revealed a positive microbial culture, and aerobes were the most common organisms involved. None of the cases contained Neisseria gonorrhoeae or Chlamydia trachomatis. Mechanical trauma can be a risk factor for cyst formation and stimulation from sexual activity can lead to cyst enlargement. Premenopausal women are most commonly affected and are usually benign. According to the New York State Department of Health census data reported in a study done in 1996 by Visco et al. [29], the incidence of Bartholin gland carcinoma was 0.023 per 100,000 woman-years in premenopausal women and 0.114 per 100,000 woman-years in postmenopausal women. Malignancies encountered include squamous carcinoma and adenocarcinoma. Although cancer is rare, Bartholin gland duct cysts that present after age 40 should be evaluated for malignancy. If excision is not to be performed, then biopsy of the cyst wall during drainage should occur. Ben-Harosh et al. [30] reported a case of a young woman who presented with a firm and irregular Bartholin gland. Pathology after excision revealed gland hyperplasia. This finding suggests that a tissue diagnosis should be made for any gland cyst with a nodular texture. Biopsy plus drainage or cyst excision should be performed, not drainage alone. Symptoms of Bartholin gland cysts and abscesses include pain to touch or during activity. Glands are usually unilaterally affected and it is rare to have simultaneous bilateral gland involvement. Upon inspection, cysts appear round and feel tense upon palpation (Figs. 14.10 and 14.11). If an abscess is present, there may be associated epithelial erythema and tenderness. Management options for Bartholin gland cysts include biopsy in women over the age of forty, observation if asymptomatic, incision and drainage, marsupialization, or gland excision. Abscesses cannot be observed and contents must be drained.
Fig. 14.10
Bartholin gland cyst
Fig. 14.11
Bartholin gland cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Skene Gland Cysts
Skene gland cysts occur after gland ductal occlusion (Fig. 14.12). The Skene glands are located at the distal urethra and are the largest paraurethral glands. Similar to other vulvar gland pathology, a cyst can become infected and form an abscess. Risk factors may include local infection or trauma. Symptoms include dyspareunia, localized pain, voiding dysfunction, and urinary obstruction. Treatment of Skene gland cysts or abscesses is with excision. Abscesses should be treated with antibiotics prior to excision to decrease the risk of spreading infection. There may be a role for cystourethroscopy as well. Lucioni et al. [31] found that Skene gland cysts may benefit from assessment to determine proximity to urethra and bladder. Cystourethroscopy was used to rule out other pathology such as urethral diverticulum or fistula and can be performed during the same operative setting prior to initiating surgical excision.
Fig. 14.12
Skene gland cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Cysts of the Canal of Nuck
A cyst of the canal of Nuck (hydrocele of the canal of Nuck) forms due to a persistent processus vaginalis. This type of cyst is a fluid-filled hernia of the peritoneum that accompanies the round ligament and extends from the inguinal canal into the labia majora. It presents with inguinal swelling with or without unilateral labia majora pain and swelling. The mass is irreducible. It can be confused with an inguinal hernia (may contain intestines); however intestinal contents should not be present if the mass is truly a cyst of the canal of Nuck. Transillumination can be used to evaluate for a cystic versus a solid mass. The finding should be evaluated for herniation preoperatively. Ultrasound or MRI are the imaging modalities of choice to aid in diagnosis and confirm preoperative suspicion. Ultrasound can be performed while the patient performs the Valsava maneuver to evaluate for this type of cyst compared to inguinal hernia (Fig. 14.13). Both ultrasound and MRI would reveal an ovoid tubular structure within the inguinal canal or labia majora [32]. Treatment is excision of the cyst and correction of any herniation that may be present. Diagnosis is confirmed with histopathology after excision.
Fig. 14.13
Longitudinal ultrasound image of cyst of the Canal of Nuck (Used with permission from Jagdale R, Agrawal S, Chhabra S, Jewan SY. Hydrocele of the Canal of Nuck: Value of Radiological Diagnosis. Journal of Radiology Case Reports. 2012 June; 6(6): 18-22. www.jrcr.org/916)
Surgical Intervention
Operative Technique
Surgical management options for vaginal cysts include incision and drainage, marsupialization, and definitive management with excision.
Incision and Drainage
Incision and drainage can provide immediate but temporary relief of symptoms. Once the incision edges reseal, secretions may recollect within the cyst. Therefore, the goal with an incision and drainage is to drain cyst contents and create a new epithelialized tract for continued drainage. The procedure can be performed as an outpatient. The patient is placed in dorsal lithotomy position and the area overlying the cyst is cleaned with an antiseptic agent. A local anesthetic such as 1 or 2 % lidocaine is infused into the cyst and the overlying vaginal epithelium where the incision is to be made. A 1 cm incision is made with a scalpel (number 15 blade) through the vaginal epithelium and cyst wall. The tips of a hemostatic or tonsil clamp may be placed within the cyst and used to lyse adhesions, thereby facilitating drainage. The fluid does not need to be cultured unless abscess is suspected. Ideally, the incision should be kept patent with a device such as a Word catheter. The tip of a Word catheter (Fig. 14.14), which is the diameter of a number 10 French Foley catheter, is placed within the cyst cavity and the balloon tip is then inflated at the opposite end of the catheter with sterile saline until the balloon is large enough to prevent the catheter from falling out (about 3 ml [33]). As there are openings on both ends of the catheter, this device allows drainage of cyst contents into the vagina. The catheter should remain in situ for 4 weeks during which time nothing should be placed in the vagina [33–35]. Broad-spectrum antibiotics to cover aerobes and anaerobes are only warranted in the case of abscess.
Fig. 14.14
Word catheter
Marsupialization
Marsupialization is a technique that was devised due to the high recurrence rates following incision and drainage without epithelialization of the tract. It is a way to create a new duct drainage tract without the use of an external device such as a Word catheter. The procedure is most commonly performed in an ambulatory operating room setting but can also be done in an office or emergency room. The patient is placed in dorsal lithotomy position. Analgesia can be achieved with local anesthesia, sedation plus local anesthesia, regional anesthesia, or most commonly general anesthesia. The vagina and vulva are prepped and draped in the usual sterile manner. A 3 cm incision with a scalpel is made in the vaginal epithelium overlying the cyst while taking care not to rupture the cyst wall (Fig. 14.15). The cyst wall is then incised (the contents will drain) with a scalpel and the cyst incision is extended to the same size as the vaginal epithelial incision (Fig. 14.16). The cyst wall is then everted with the use of Allis clamps that are placed circumferentially around the incision to grasp the cyst wall plus overlying vaginal epithelium in each bite. A hemostat is used to lyse adhesions within the cyst and the cyst is then irrigated (Fig. 14.17). The cyst wall edge is then circumferentially sutured to its overlying vaginal epithelium with either 2-0 or 3-0 delayed-absorbable—Vicryl® (Ethicon, Inc, Blue Ash, OH) is commonly used—interrupted sutures (Fig. 14.18). Generally by 4–6 weeks after the procedure, the opening of the duct decreases in size to less than 1 cm. Risks of marsupialization include cyst recurrence and rarely abscess formation. Marsupialization requires better surgical site exposure, a larger incision, more suturing, greater levels of analgesia, and more time to perform than incision and drainage. For these reasons, the use of marsupialization has decreased since the introduction of Word catheter use at the time of incision and drainage.
Fig. 14.15
Skene gland cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.16
Cyst wall incision (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.17
Lysis of adhesions within cyst wall (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.18
End result after marsupialization of cyst wall to vaginal epithelium
Excision
The procedure for excision of a vaginal cyst is similar regardless of the type of cyst. When performing an office physical exam, one should inspect the size of the cyst. Consideration should be taken to perform excision in the operating room for larger cysts. Although there is no cutoff as to what size cyst is unlikely to be successfully excised in the office setting, cysts greater than 2 cm generally require dissection that may be too extensive for an office procedure. In addition, preoperative assessment may be performed with imaging to evaluate the relationship of the cyst to surrounding structures depending on its vaginal location on exam. If preoperative evaluation reveals the cyst to be in close proximity to the bladder or ureters, the procedure should take place under general anesthesia. Prior to cyst excision, consideration can be taken to placing ureteral catheters. Integrity of the urethra and bladder can be evaluated intraoperatively with the use of cystourethroscopy. Surgical intervention in the operating room may be performed under local or general anesthesia. The patient is placed in the dorsal lithotomy position and then prepped and draped in the usual sterile fashion.
The technique for excision of a vaginal cyst is as follows. Initially, adequate exposure of the cyst must be ensured. Vaginal retractors or a Lone Star Retractor System™ (Cooper Surgical, Inc., Stafford, Texas) may be used to assist with visualization (Fig. 14.19). Stay sutures with 0 Vicryl may be placed to keep orientation above or below the cyst, such as at the 12 O’clock position. The vaginal epithelium is infused with a dilute vasopressin solution using a thin 22-gauge or 25-gauge needle. It is our practice to dilute 20 units of vasopressin in 100 ml normal saline. The purpose of this infiltration is for hydrodissection and hemostasis. A scalpel is used to make a longitudinal superficial incision through the vaginal epithelium overlying the cyst wall. The vaginal wall is then dissected circumferentially off the cyst until the base is reached and the cyst is entirely freed (Fig. 14.20). Dissection is carried out sharply with Metzenbaum scissors or a knife as well as bluntly while using electrocautery sparingly as needed. The direction of dissection is inferior to superior as this technique minimizes disruption in visualization of the surgical field with blood. Attention is taken not to rupture the cyst during the process. The base is often the location of blood supply for the cyst, and therefore after the cyst is removed it may bleed. This base should be sutured with 3-0 Vicryl in a figure-of-eight fashion or in a running-locking technique until hemostasis is noted. The vascular supply to the cyst can also be clamped with a hemostat and suture ligated with 2-0 or 3-0 Vicryl. Electrocautery may be used with careful consideration of underlying structures. Complete removal of the cyst (Fig. 14.21) is essential because if residual tissue is left behind, cyst formation may recur. If potential space (Fig. 14.22) is present in the fibromuscular layer deep to the vaginal epithelium, this layer should be closed with 2-0 or 3-0 Vicryl sutures in an interrupted fashion. The overlying vaginal epithelium is then sutured in a running or running-locking fashion with 2-0 Vicryl (Fig. 14.23). The overlying vaginal epithelium rarely needs to be trimmed prior to closure as trimming may cause tension leading to scarring, pain, or dyspareunia.
Fig. 14.19
Skene gland (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH.)
Fig. 14.20
Vaginal wall dissection off the underlying cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.21
Skene gland cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.22
Potential space after excision of cyst (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
Fig. 14.23
Closure of vaginal epithelium (Courtesy of Howard Goldman, MD, Department of Urology, Cleveland Clinic, Cleveland, OH)
In the cases of larger cysts that impede anatomical visualization or with inadvertent cyst rupture (Figs. 14.24 and 14.25), the cyst may be intentionally drained and then the cyst wall is dissected (Figs. 14.26, 14.27, and 14.28) or destroyed [24]. Potential space and vaginal epithelium should be closed in the aforementioned manner (Figs. 14.29, 14.30, and 14.31). The excised cyst or a portion of the cyst wall should be sent to pathology for examination. We recommend cystourethroscopy to be performed at the end of any vaginal cyst excisional procedure to evaluate for urinary tract injury. Risks of excision include bleeding, hematoma formation, cellulitis, cyst recurrence, pain, dyspareunia, and damage to deep and surrounding anatomical structures.
Fig. 14.24
Cyst rupture during dissection of anterior vaginal wall cyst
Fig. 14.25
Drainage of a posterior vaginal cyst contents
Fig. 14.26
Dissection of posterior vaginal cyst wall off of vaginal epithelium and underlying endopelvic fascia
Fig. 14.27
Dissection of posterior vaginal cyst wall off of vaginal epithelium and underlying endopelvic fascia
Fig. 14.28
Allis clamps lifting posterior vaginal cyst wall
Fig. 14.29
Closure of potential space after removal of posterior vaginal cyst
Fig. 14.30
Closure of posterior vaginal epithelium after excision of cyst
Fig. 14.31
Completed closure of posterior vaginal wall
Vulvar Considerations
The techniques for surgical management of vulvar cysts such as incision and drainage, marsupialization, and excision are similar to that of vaginal cysts, with a few variations based on the type of vulvar cyst that is present.
Vulvar Epidermal Inclusion Cysts
Asymptomatic and noninfected vulvar epidermal inclusion cysts can be observed. Excision can be performed for symptomatic cysts where the type of excision is determined based on cyst size. Cysts that are 1 cm or smaller can be excised utilizing a wedge incision technique. The wedge-shaped specimen removes its encompassing skin, subcutaneous tissue, and the cyst in its entirety. Cysts larger than 1 cm require the usual excision technique starting with a skin incision, sharp dissection of skin off the underlying cyst wall, and complete removal of the cyst. Attention must be paid not to grab the cyst wall during dissection in order to avoid rupture. The skin can be held with Adson forceps while fine dissection is carried out with Stevens tenotomy scissors. The wound is closed in layers and excess skin is cut as needed for the skin to realign properly. After excision of vulvar cysts, skin is closed in an interrupted or subcuticular running fashion with 4-0 delayed-absorbable sutures. A pressure dressing can be applied to prevent hematoma formation. Alternatively to excision, a punch biopsy of the lesion and drainage of cyst contents through the biopsy site can be performed.
Bartholin Gland Cysts
As Bartholin gland duct cysts and abscesses are common enough and often symptomatic, they require special mention. Abscesses and symptomatic cysts should be treated. Treatment options include incision and drainage with or without Word catheter placement, marsupialization, and excision. Other procedures to obliterate the cyst wall such as incision plus the use of silver nitrate stick insertion into the cyst or abscess [36, 37] or carbon dioxide laser vaporization [38, 39] have been described but are not commonly employed. A recent review by Wechter et al. [33] looked at recurrence rates after various treatments of Bartholin gland cysts and abscesses including aspiration, incision and drainage, marsupialization, excision, silver nitrate ablation, and carbon dioxide laser excision. Recurrence rates varied from 0 to 38 % and were highest after incision or aspiration alone. There were no recurrences noted after marsupialization; however no best treatment approach was identified. Patients must be counseled regarding the risk of cyst reaccumulation when any portion of the gland is left in situ. Patients also need to be made aware that gland function and ability to form vaginal secretions may be reduced if the gland is removed in its entirety. These facts along with the patient’s age and personal history of Bartholin gland cyst or abscess recurrence should be used when selecting a procedure.
The technique for Bartholin gland cyst incision and drainage, marsupialization, and excision may be carried out as mentioned above. A linear incision is made on the medial aspect of the vestibule overlying the cyst roughly 1 cm distal and parallel to the hymen. The incision should be on the vaginal mucosa and not on the vulvar skin. This location mimics the site of the glands’ natural orifices at the 5 and 7 O’clock positions. If performing an incision and drainage, the incision is generally less than 1 cm. After drainage, a Word catheter should be placed and remain in situ for at least 4 weeks. Kushnir et al. [40] described the use of a small loop of plastic tubing that was secured in place after incision and drainage of a Bartholin gland abscess when a Word catheter was not available. The technique was found to be a successful replacement to the Word catheter as there was no evidence of the abscess and the patient healed 3 weeks after the procedure.
If marsupialization or excision is to take place, the incision is created in the same location but is extended to 3 cm in length while remaining parallel with the hymen throughout the incision. Cultures should be obtained for N. gonorrhoeae and C. trachomatis during drainage. Complete excision should not be performed in the presence of suspected infection prior to the administration of antibiotics. If excision is being performed, care must be taken as the rectum is located just posterior to the gland. A finger may be placed in the rectum during dissection to differentiate between rectum and cyst. Generally the blood supply arises from the posterosuperior aspect of the cysts and therefore dissection should be carried out heading toward this final location. The vascularity of the Bartholin gland and its associated cysts requires that dead space remaining after cyst excision should be closed in layers to prevent hematoma formation. Surgical complications include bleeding from venous channels that can cause significant hematoma formation. In addition to suture ligation techniques, direct pressure should be applied and a drain may be placed intraoperatively if needed.
Postoperative care includes ice packs initially to decrease swelling and pain from scarring. Nothing should be placed per vagina for at least 4 weeks, at which time the site should be inspected. Warm sitz baths and proper hygiene should be encouraged during recovery. Broad-spectrum antibiotics need only be given when treating abscesses with accompanying cellulitis or if postoperative cellulitis develops. Although rare, there have been case reports of rectovaginal fistula developing as a complication to Bartholin gland excision. Zoulek et al. [41] describe a case of a 43-year-old woman who was found to have a rectovaginal fistula immediately after having had a Bartholin gland excision procedure. Care should be taken to close dead space in layers in attempt to prevent this rare but serious complication.
Cysts of the Canal of Nuck
Surgical treatment of a cyst of the canal of Nuck begins with a vertical incision into the labia majora to expose the underlying cyst. If blood vessels are encountered while dissecting in the subcutaneous tissue, they can be suture ligated with 4-0 Vicryl. The cyst is then grasped with Allis clamps and freed using sharp dissection on all sides except the superior attachment. Metzenbaum scissors utilizing the flash technique are used to ensure there is no underlying intestine and subsequently the cyst is entered. A finger is placed into the cyst to palpate the external inguinal ring. Any peritoneal lining is excised from the cyst, and the external inguinal ring is closed. The superior portion of the cyst is then closed with a purse-string suture and the cyst is excised and freed. The vulva including the skin is then closed in layers with 3-0 Vicryl sutures. If an inguinal hernia is present, an inguinal hernia repair should be performed. Although surgical excision is the treatment of choice, sonographically guided aspiration has been performed for symptom relief. This technique does entail the risk of bowel puncture in the rare instance of intestinal herniation, so special care must be taken [42].
Summary
In conclusion, both vulvar and vaginal cysts are often asymptomatic and discovered on routine gynecological examination. The evaluation of these cysts includes a detailed history, thorough physical examination, and possibly imaging. Asymptomatic cysts can be observed while symptomatic or infected cysts should be actively managed. Patient demographics and cyst characteristics should guide the clinician as to what surgical procedure to employ. Techniques include incision and drainage, marsupialization, and excision. Incision and drainage with epithelialization of the drainage tract as well as marsupialization have good outcomes with low complication and recurrence rates. Definitive treatment is achieved by cyst excision. Clinicians should have a low threshold to biopsy of any concerning or recurrent lesion.
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